Υπερτασικός 69 ετών με διαβητική νεφροπάθεια νοσηλεία για οξύ στεφανιαίο σύνδρομο για το οποίο θα κάνει προγραμματισμένη PCI

Transcript

1 Υπερτασικός 69 ετών με διαβητική νεφροπάθεια νοσηλεία για οξύ στεφανιαίο σύνδρομο για το οποίο θα κάνει προγραμματισμένη PCI ΜΑΡΙΑ ΜΑΡΚΕΤΟΥ ΔΙΕΥΘ. ΕΣΥ ΠΑΝΕΠΙΣΤΗΜΙΑΚΟ ΝΟΣΟΚΟΜΕΙΟ ΗΡΑΚΛΕΙΟΥ

2 Conflict of interest: none

3 Κλινικό Περιστατικό o Ασθενής 69 ετών o Ιστορικό αρτηριακής υπέρτασης από 15-ετίας και ΣΔ τύπου 2 από 12- ετίας o Αναφέρει προκάρδιο συσφιγκτικό αλγος από 2ώρου και στηθάγχη προσπάθειάς από 3- μήνου

4 Φαρμακευτική αγωγή o Ιρμπεζαρτάνη/υδροχλωροθειαζίδη 300/12,5 mg o Συνδυασμό βιλδαγλιπτίνης και μετφορμίνης (50/1000mg) oγλικλαζίδη 3οmg o ατορβαστατινη 20mg

5 Κατά την εισαγωγή του. o ΑΠ = 185/105mm Hg o Hct =42,5% o S-crea = 1,3 mg/dl, otroponine I=1,2ng/mL o Glucose= 99mg/dL o LDL-C=90mg/dL ohba1c = 7.1%

6 Cardiovascular Mortality Rate/10,000Person-yr Systolic BP and CV Death Rates in Type 2 Diabetes Nondiabetic Patients Diabetic Patients < Systolic Blood Pressure (mm Hg) Stamler J et al. Diabetes Care. 1993;16:

7 Screening Tools: egfr Considered the best overall index of kidney function. Moderately Normal GFR varies according to age, sex, and body size, and declines with age. reduced egfr=58ml/mi CKD-EPI Creatinine Equation (2009) to estimate GFR. kidney Other useful calculators related to kidney disease include MDRD and Cockroft Gault. n/1.73m function 2 GFR calculators are available online at

8 Screening Tools: ACR Urinary albumin-to-creatinine ratio (ACR) is calculated by dividing albumin concentration in milligrams by creatinine concentration in grams. Creatinine assists in adjusting albumin levels for varying urine concentrations, which allows for more accurate results versus albumin alone. 365mg/dL Spot urine albumin-to-creatinine ratio for quantification of proteinuria First morning void preferable 24hr urine test rarely necessary

9 Hypertension-induced renal dysfunction hypertension nephropathy longterm hypertension causes kidney damage ischaemic nephropathy - atherosclerotic changes in macrovessels (altogether with diabetes, hyperlipidaemia).. renovascular hypertension vascular nephropathy (nephrosclerosis) affection of smaller renal vessel causes kidney dysfunction renovascular kidney disease vascular nephrosclerosis + ischemic nephropathy

10 Επιπολασμός της Νεφρικής Νόσου Τελικού Σταδίου ανά αίτιο 160 Επιπολασμός ανά εκατομύριο Πληθυσμού Σπειραματονεφρίτις Υπέρταση Διαβήτης Έτος United States Renal Data System (USRDS) 2000 Annual Data Report

11 Diabetic nephropathy A microvascular complication of diabetes marked by albuminuria and a deteriorating course from normal renal function to ESRD.

12 Diabetic Nephropathy Over 40% of new cases of endstage renal disease (ESRD) are attributed to diabetes. Incidence of ESRD Resulting from Primary Diseases (1998) 19% In 2001, 41,312 people with diabetes began treatment for endstage renal disease. In 2001, it cost $22.8 billion in public and private funds to treat patients with kidney failure. Minorities experience higher than average rates of nephropathy and kidney disease 3% 12% 23% 43% Diabetes Hypertension Glomerulonephritis Cystic Kidney Other Causes

13 Microalbuminuria Early indicator of diabetic nephropathy (diabetic damage to kidneys). This is the presence of small particles of protein in the urine. Passage of protein through the glomeruli (or filtering units of the kidney, damages the kidney.) -Detected in urinalysis (UA) -Presence of microalbuminuria indicates 16.5X increased risk of cardiovascular mortality over 3.6 years (Bell, 2009).

14 Epidemiology About 20-30% of patients with type I DM develop microalbuminuria, less than half progress to overt nephropathy Incidence of ESRD is 16% at 30 years. 5-60% of type II DM patients develop DN, depending on ethnicity

15 When diabetic retinopathy coexists with albuminuria, the likelihood of diabetic nephropathy is very high Suggests the presence of the specific pattern of nodular glomerulosclerosis, the so called Kimmelstiel-Wilson lesion

16 Pathophysiology Hyperglycaemia Glycation endproducts (AGE) Vasoactive systems Hemodynamic changes Proteinuria activation of signal transduction PKC, MAP kinase, NF-κB Growth factors Tubulointerstitial fibrosis Cell cycle changes Reactive oxygen radicals Renal failure Glomerulosclerosis

17 Pathogenesis Genetic predisposition to or protection from diabetic nephropathy Differences in prevalence of microalbuminuria, ESRD in different patient populations Only half of patients with poor glycemic control will develop diabetic nephropathy Multiple genes may be involved

18 Classification of CKD Based on GFR and Albuminuria Categories: Heat Map Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. Kidney Int Suppls. 2013;3:1-150.

19 Treatment Glycemic control Hypertension control Dietary protein restriction RAS blockade

20 Blood pressure reduction is the most potent CVD risk reducer in type 2 diabetes

21 GFR (ml/min/έτος) Meta Analysis: Lower Mean BP Results in Slower Rates of Decline in GFR in Diabetics and Non- Diabetics meanbp (mmhg) r = 0.69; P < Untreated HTN /85 140/90 Bakris GL, et al. Am J Kidney Dis. 2000; 36:

22 Μεταβολή του GFR Barnett et al; Acta Diabetol. 2005; 42 : S42 - S49

23

24 Anti-ischeamic drugs in the acute phase 2015 ESC guidelines

25 Oral antiplatelet therapy 2015 ESC guidelines

26 Anti-coagulation 2015 ESC guidelines

27 ESC/EAS 2016 guidelines

28 CKD patient safety approach Patient Safety Following CKD detection Improved diagnosis creates opportunity for strategic preservation of kidney function Fink et al. Am J Kidney Dis. 2009,53:

29 Risk criteria mandating invasive therapy 2015 ESC guidelines

30 Risk criteria mandating invasive therapy GRACE score = 135 Interpretation: Mortality in hospital: Intermediate risk - Mortality 2-5% Mortality at 6 months: High risk - Mortality >11% 2015 ESC guidelines

31 Bleeding score Bleeding score 43: High risk Risk of in-hospital major bleeding 10,1%

32 Indications for revascularization in patients with nste-acs 2014ESC/EACTS guidelines

33 2015 ESC guidelines

34

35 Prevention of contrastinduced nephropathy 2014ESC/EACTS guidelines

36 Angiography and PCI: two in one? Although performing diagnostic and interventional procedures separately reduces the total volume exposure to contrast media, the risk of renal atheroembolic disease increases with multiple catheterizations. In CKD patients with diffuse atherosclerosis, a single invasive approach (diagnostic angiography followed by ad hoc PCI) may be considered, but only if the contrast volume can be maintained, 4 ml/kg. The risk of CIN increases significantly when the ratio of total contrast volume to GFR exceeds 3.7:1

37

38 Recommendation for the type of revascularization(cabg or PCI) in patients with SCAD with suitable coronary anatomy for both procedures and low predicted surgical mortality

39 Stone et al. Circulation 2001;104:

40 Diabetes and PCI: Factors influencing outcome Inflammation Prothrombotic state Endothelial dysfunction CAD progression and/or worse outcome in PCI Restenosis Renal dysfunction LV dysfunction PAD Atherosclerosis burden Eur Heart J 2004;25:190-8

41 Patti et al. Am J Cardiol 2008; 102:

42 Akin et al. Am J cardiol 2010;106:

43 Blood pressure treatment strategies ESH ESC guidelines 2013

44 % Reduction In Relative Risk Διαβήτης: Αυστηρός γλυκαιμικός έλεγχος vs αυστηρού ελέγχου της ΑΠ και Καρδιαγγειακά συμβάματα στη UKPDS 0 5% AEE Όλα τα σχετιζόμενα με το διαβήτη συμβάματα Θάνατοι λόγω Μικροαγγειακές Διαβήτη επιπλοκές % 10% % -30 * 32% 32% * 37% % * Αυστηρός γλυκαιμικός έλεγχος (HbA 1C : 8,2%) Αυστηρός έλεγχος της ΑΠ (Μέση ΑΠ 144/82 mmhg) *P <0.05 σε σύγκριση με αυστηρό γλυκαιμικό έλεγχο * Bakris GL, et al. Am J Kidney Dis. 2000;36(3):

45 Primary Outcome Experience in the Six Pre-specified Subgroups of Interest *Treatment by subgroup interaction

46 Participants with CKD at Baseline Renal Disease Outcomes Primary CKD outcome Intensive Standard Events %/yr Events %/yr HR (95% CI) P (0.42, 1.87) % reduction in (0.36, 2.07) 0.75 egfr * Dialysis (0.19, 1.54) 0.27 Kidney transplant Secondary CKD Outcome Incident albuminuria** (0.48, 1.07) 0.11 Participants without CKD at Baseline Secondary CKD outcomes 30% reduction in egfr* (2.44, 5.10) < Incident albuminuria** (0.63, 1.04) 0.10 *Confirmed on a second occasion 90 days apart **Doubling of urinary albumin/creatinine ratio from <10 to >10 mg/g

47 Glucose Control in CKD Target HbA1c ~7.0% Can be extended above 7.0% with comorbidities or limited life expectancy, and risk of hypoglycemia Risk of hypoglycemia increases as kidney function becomes impaired Declining kidney function may necessitate changes to diabetes medications and renallycleared drugs

48 Recommendations for long term management

49 Combined effect of ARB/ACEi with MRB may further decrease microalbuminuria

50

51 Healthy Lifestyle

52 The Persistence of memory Salvador Dali